Tarsal-metatarsal joint procedure utilizing compressor-distractor and instrument providing sliding surface

ABSTRACT

A compressor-distractor device may be used during a surgical procedure, such as a surgical procedure to correct a bunion deformity. In some examples, the compressor-distractor includes first and second engagement arms having first and second pin-receiving holes, respectively. The first and second pin-receiving holes may be angled relative to each other. The compressor-distractor may also include an actuator operatively coupled to the first and second engagement arms. In some example uses, a clinician may pin a first surgical device to a patient&#39;s bones use a pair of parallel pins. After removing the surgical device over the parallel pins, the clinician may thread the parallel pins through the angled first and second pin-receiving holes of the compressor-distractor, causing the bones to move relative to each other. Thereafter, the clinician may actuate the actuator on the compressor-distractor to move the bones towards and/or away from each other.

RELATED APPLICATIONS

This application claims the benefit of U.S. Provisional Application No.62/805,208 filed Feb. 13, 2019, the entire contents of which areincorporated herein by reference.

TECHNICAL FIELD

This disclosure relates generally to devices and techniques forrepositioning bones and, more particularly, to devices and techniquesfor repositioning bones in the foot.

BACKGROUND

Bones within the human body, such as bones in the foot, may beanatomically misaligned. For example, one common type of bone deformityis hallux valgus, which is a progressive foot deformity in which thefirst metatarsophalangeal joint is affected and is often accompanied bysignificant functional disability and foot pain. The metatarsophalangealjoint is laterally deviated, resulting in an abduction of the firstmetatarsal while the phalanges adduct. This often leads to developmentof soft tissue and a bony prominence on the medial side of the foot,which is called a bunion.

Surgical intervention may be used to correct a bunion deformity. Avariety of different surgical procedures exist to correct buniondeformities and may involve removing the abnormal bony enlargement onthe first metatarsal and/or attempting to realign the first metatarsalrelative to the adjacent metatarsal. Surgical instruments that canfacilitate efficient, accurate, and reproducible clinical results areuseful for practitioners performing bone realignment techniques.

SUMMARY

In general, this disclosure is directed to devices and techniques thatcan be used during a surgical bone realignment procedure. In someexamples, a system is described that includes a compressor-distractordevice and an instrument defining a sliding surface. Thecompressor-distractor device and the instrument defining the slidingsurface can be utilized together during a bone repositioning procedure.For example, during a bone repositioning procedure, a bone such as ametatarsal on a foot may be moved from an anatomically misalignedposition to an anatomically aligned position with respect to anotherbone, such as an adjacent metatarsal. One end of the metatarsal and afacing end of adjacent cuneiform may be prepared, such as by cutting theends of the metatarsal and adjacent cuneiform.

To facilitate clean-up and compression between the two bone ends, thecompressor-distractor device may be attached to both the metatarsal andcuneiform. The compressor-distractor device can then be actuated to movethe metatarsal away from the cuneiform. This can open up the spacebetween the two bone faces, for example, to allow the clinician topreform further cleanup and/or preparation on a bone face and/or toremove debris from the space between the two bone faces. In either case,the compressor-distractor device can be actuated to move the metatarsaltoward the cuneiform, for example, to compress the two bone facestogether for fixation. As the metatarsal is moved toward the cuneiform,the prepared end face and/or a side of the metatarsal may have atendency to catch or frictionally interfere with adjacent bone and/ortissue. For this and other reasons, an instrument defining a slidingsurface according to the disclosure may be utilized with thecompressor-distractor device. The instrument may be positioned betweenthe prepared metatarsal and an adjacent metatarsal. For example, theinstrument may be positioned between the prepared end face and/or alateral side of the metatarsal and an adjacent metatarsal. The slidingsurface defined by the instrument may provide a comparatively lowfriction surface (e.g., compared to otherwise interfering tissue and/orbone) against which the metatarsal can slide as it is moving toward thecuneiform. For example, the sliding surface defined by the instrumentcan be a laterally-positioned bearing surface against which themetatarsal can slide as the metatarsal is moved generally axially (e.g.,in the proximal direction).

In some implementations, the instrument defining the sliding surface maybe positioned substantially stationary (non-moving) as the metatarsal ismoved generally axially toward an opposing cuneiform. In otherimplementations, the instrument defining the sliding surface may bemoved as the metatarsal is moved generally axially toward an opposingcuneiform. For example, the clinician may grasp or otherwise hold theinstrument defining the sliding surface and manipulate the position ofthe instrument as the metatarsal is compressed toward and/or against theopposing cuneiform. The clinician may move the instrument toward theopposing cuneiform (e.g., parallel to the metatarsal being moved) at thesame rate as the metatarsal is being moved or at a different rate thanthe rate at which the metatarsal is being moved. Accordingly, themetatarsal being moved may or may not move relative to the instrumentdefining the sliding surface as both the instrument and the metatarsalare moved (e.g., proximally). In some applications, the clinician maybias (e.g., push) the instrument defining the sliding surface mediallywhile moving the metatarsal generally axially toward the opposingcuneiform. This medial biasing force can help deflect and redirect themetatarsal being moved into alignment with the opposing cuneiform, asthe metatarsal being moved may have a tendency to shift laterally duringmovement.

A compressor-distractor used according to the present disclosure canhave a variety of different configurations. In some examples, thecompressor-distractor includes first and second engagement arms thatdefine first and second pin-receiving holes, respectively. The first andsecond pin-receiving holes can receive pins that are inserted intoadjacent bones being compressed and/or distracted. In this way, the pinsinserted through the pin-receiving holes can function to attach to thecompressor-distractor to the bones. The first and second pin-receivingholes can be parallel to each other, e.g., to facilitate sliding thecompressor-distractor on and/or off the pins without adjusting therelative positioning of the pins. Alternatively, the first and secondpin-receiving holes can be angled relative to each other. This may causethe pins and, correspondingly bones to which the pins are attached, torotate as the compressor-distractor is placed over the pins.

The instrument defining the sliding surface according to the disclosurecan likewise have a variety of different configurations. In general, anymechanical instrument that provides separation between adjacent bonesand a surface against which one bone can slide can function as aninstrument defining a sliding surface according to the disclosure. Insome examples, the instruction providing the sliding surface is alsoused as a fulcrum providing pivot surface about which a bone is rotatedduring the procedure. For example, during realignment of one metatarsalrelative to an adjacent metatarsal, a distal portion of the onemetatarsal may be moved toward the second metatarsal in a transverseplane. By positioning the instrument between the two metatarsals, theproximal portion of the one metatarsal may be pivoted about the fulcrum,reducing the intermetatarsal angle between the metatarsals. In thisregard, the instrument defining the sliding surface may also function asa fulcrum.

In some implementations, the instrument defining the sliding surfaceincludes a body and a handle. The body is configured to be inserted inan intermetatarsal space between adjacent metatarsals. The handle isoperatively connected to the body. The handle may project at a non-zerodegree angle from the body to define a tissue retraction space betweenthe handle and the body. Other instrument and/or handle configurationscan be used though, and it should be appreciated that the disclosure isnot limited in this respect.

The system that includes the compressor-distractor and instrumentdefining the sliding surface may be used during a surgical procedure inwhich one or more other surgical instruments are also used. For example,the compressor-distractor and sliding surface instrument may be usedduring a procedure in which a bone preparation guide is also deployedfor preparing the bones that are to be subsequent distracted and/orcompressed together using the compressor-distractor and sliding surfaceinstrument. The bone preparation guide may be pinned to two differentbone portions, which may be two different bones separated by a joint ortwo portions of the same bone (e.g., separated by a fracture or break).In either case, one end of the bone preparation guide may be pinned toone bone portion while another end of the bone preparation guide may bepinned to the other bone portion. The bone preparation guide may bepinned to the two bone portions using a pair of pins that extendparallel to each other through a pair of fixation apertures on the bonepreparation guide, optionally along with one or more additional pinsthat may extend through one or more additional fixation apertures on thebone preparation guide that may be skewed or angled at a non-zero degreeangle relative to the parallel pins. In some configurations, the bonepreparation guide defines one or more slots through which a bonepreparation instrument (e.g., cutting instrument) is inserted to prepareopposed end faces of the two bones.

After utilizing the bone preparation guide to prepare the two boneportions, the clinician may remove any angled pins (e.g., non-parallelpins) inserted through the bone preparation guide into the boneportions, leaving the parallel-aligned pins (e.g., a pair of parallelpins) in the bone portions. The bone preparation guide can be slide ortranslated along the parallel-aligned pins until the fixation aperturesof the bone preparation guide come off the distal ends of the pins. Atthis point, the bone preparation guide may be separated from the pins,leaving the pins in the bone portions. The compressor-distractor canthen be installed over the pins by threading the parallel-aligned pinsthrough the first and second pin-receiving holes of thecompressor-distractor.

After installing the compressor-distractor on the pins, the clinicianmay actuate the actuator to move the first and second engagement armsaway from each other and, as a result, move the bone portions away fromeach other. This can provide an enlarged separation gap between the boneportions for cleaning the inter-bone space in anticipation for fixation.For example, the clinician may remove bone chips and/or tissue debrisfrom the inter-bone space between the two bone portions, further cut orprepare an end face of one or both bone portions, or otherwise preparefor fixation.

Before or after distracting the two bone portions, the clinician mayinsert the instrument defining the sliding surface between a boneportion that is or will be distracted and an adjacent bone to the boneportion that is or will be distracted. For example, the clinician mayinsert the instrument defining the sliding surface between a metatarsalthat is or will be distracted from a cuneiform and an adjacentmetatarsal (e.g., laterally-adjacent metatarsal). The opposite side ofthe instrument from the side defining the sliding surface may or may notcontact the adjacent metatarsal. When subsequently actuating thecompressor-distractor, the distracted metatarsal may move proximallytoward the cuneiform to close the space between the metatarsal and thecuneiform. As the distracted metatarsal is moved proximally, themetatarsal can contact and/or slide along the sliding surface positionedbetween the metatarsal and adjacent metatarsal. This provision of thesliding surface can help facilitate smooth compression of the metatarsalto the cuneiform and/or help prevent movement of the metatarsal beingcompressed in the frontal and/or transverse planes during compression.

In some applications, the clinician can insert the instrument definingthe sliding surface between a metatarsal that is or will be distractedfrom a cuneiform and an adjacent metatarsal and leave the instrument ina substantially fixed position as the metatarsal is moved toward anopposed cuneiform. In other applications, the clinician may move theinstrument defining the sliding surface with the metatarsal as themetatarsal is moved toward the opposed cuneiform. Accordingly, theinstrument defining the sliding surface may slide proximally with themetatarsal being moved to contact and/or compress against the opposedcuneiform.

In practice, the clinician may move the first and second engagement armsof the compressor-distractor toward each other until the end faces ofthe bone portions are pressing against each other, resulting in acompressive force being applied to the bone portions. In some example,the clinician then fixates the bone portions by applying one or morefixation members to the bone portions.

In one example, a method is described that includes attaching acompressor-distractor to a first metatarsal and attaching thecompressor-distractor to a medial cuneiform. The method includesactuating the compressor-distractor to move the first metatarsal awayfrom the medial cuneiform and inserting an instrument defining a slidingsurface between the first metatarsal and a second metatarsal. The methodfurther involves actuating the compressor-distractor to move the firstmetatarsal toward the medial cuneiform, thereby causing the firstmetatarsal to slide across the sliding surface of the instrument as thefirst metatarsal is moved toward the medial cuneiform.

The details of one or more examples are set forth in the accompanyingdrawings and the description below. Other features, objects, andadvantages will be apparent from the description and drawings, and fromthe claims.

BRIEF DESCRIPTION OF THE DRAWINGS

FIGS. 1A and 1B are front views of a foot showing a normal firstmetatarsal position and an example frontal plane rotational misalignmentposition, respectively.

FIGS. 2A and 2B are top views of a foot showing a normal firstmetatarsal position and an example transverse plane misalignmentposition, respectively.

FIGS. 3A and 3B are side views of a foot showing a normal firstmetatarsal position and an example sagittal plane misalignment position,respectively.

FIG. 4 is a perspective view of an example compressor-distractoraccording to disclosure.

FIG. 5 is a frontal plane view of the example compressor-distractor ofFIG. 4 showing an example angular offset between pin-receiving holes.

FIG. 6 is a sagittal plane view of the example compressor-distractor ofFIG. 4 showing an example angular offset between pin-receiving holes.

FIG. 7 is a side view of an example configuration of thecompressor-distractor of FIG. 4 .

FIG. 8 is a perspective view of one example instrument defining asliding surface.

FIG. 9 illustrates an example system of different sized instrumentsdefining sliding surfaces.

FIGS. 10A and 10B are different perspective views of another exampleinstrument defining a sliding surface that can be used during a bonecorrection procedure.

FIG. 11 illustrates an alternative arrangement of surface features thatmay be used on the example instrument defining a sliding surface ofFIGS. 10A and 10B.

FIGS. 12A and 12B are perspective and side views, respectively, of anexample instrument defining a sliding surface having two sliding surfacebodies.

FIGS. 13A and 13B are perspective and side views, respectively, of anexample multidimensional instrument defining a sliding surface havingends of different dimensions and a unitary body.

FIG. 14 is a top plan view of an example bone preparation guide that canbe used with a compressor-distractor and instrument defining a slidingsurface.

FIG. 15 is a perspective view of an example bone preparing guide,spacer, and tissue removing instrument check member that can be usedwith a compressor-distractor and instrument defining a sliding surface.

FIG. 16 is a side perspective view of a foot depicting a bonepreparation instrument inserted into a joint.

FIG. 17 is a perspective view of a foot depicting a bone positioningguide on the foot prior to an alignment of a first metatarsal.

FIG. 18 is a perspective view of a foot depicting a bone positioningguide on the foot after an alignment of a first metatarsal and with aspacer inserted into a joint space.

FIG. 19 is a perspective view of a foot depicting a bone preparationguide positioned on the foot.

FIG. 20 is a perspective view of a foot depicting a bone preparationguide on the foot with pins inserted through the bone preparation guide.

FIG. 21 is a perspective view of a foot depicting a removal of a bonepreparation guide.

FIG. 22 is a perspective view of a foot showing an example distractedposition of a compressor-distractor in which a first metatarsal isspaced from a medial cuneiform.

FIG. 23 is a perspective view of a foot showing an example positioningof an instrument defining a sliding surface relative to a firstmetatarsal.

FIG. 24 is a perspective view of a foot showing an example positioningof an instrument defining a sliding surface relative to a firstmetatarsal following compression using a compressor-distractor.

FIG. 25 is a side perspective view of a foot depicting bone platesacross a joint between first and second bones.

The details of one or more examples are set forth in the accompanyingdrawings and the description below. Other features, objects, andadvantages will be apparent from the description and drawings, and fromthe claims.

DETAILED DESCRIPTION

In general, the present disclosure is directed to devices and techniquesfor correcting a misalignment of one or more bones. The discloseddevices and techniques can be implemented in a surgical procedure inwhich one bone portion is realigned relative to another bone portion. Insome examples, the technique is performed on one or more bones in thefoot or hand, where bones are relatively small compared to bones inother parts of the human anatomy. For example, the foregoing descriptiongenerally refers to example techniques performed on the foot and, moreparticularly a metatarsal and cuneiform of the foot. However, thedisclosed techniques may be performed on other bones, such as the tibia,fibula, ulna, humerus, femur, or yet other bone, and the disclosure isnot limited in this respect unless otherwise specifically indicated. Insome applications, however, the disclosed techniques are used to correcta misalignment between a metatarsal (e.g., a first metatarsal) and asecond metatarsal and/or a cuneiform (e.g., a medial, or first,cuneiform), such as in a bunion correction surgery.

FIGS. 1-3 are different views of a foot 200 showing example anatomicalmisalignments that may occur and be corrected according to the presentdisclosure. Such misalignment may be caused by a hallux valgus (bunion),natural growth deformity, or other condition causing anatomicalmisalignment. FIGS. 1A and 1B are front views of foot 200 showing anormal first metatarsal position and an example frontal plane rotationalmisalignment position, respectively. FIGS. 2A and 2B are top views offoot 200 showing a normal first metatarsal position and an exampletransverse plane misalignment position, respectively. FIGS. 3A and 3Bare side views of foot 200 showing a normal first metatarsal positionand an example sagittal plane misalignment position, respectively. WhileFIGS. 1B, 2B, and 3B show each respective planar misalignment inisolation, in practice, a metatarsal may be misaligned in any two of thethree planes or even all three planes. Accordingly, it should beappreciated that the depiction of a single plane misalignment in each ofFIGS. 1B, 2B, and 3B is for purposes of illustration and a metatarsalmay be misaligned in multiple planes that is desirably corrected.

With reference to FIGS. 1A and 2A, foot 200 is composed of multiplebones including a first metatarsal 210, a second metatarsal 212, a thirdmetatarsal 214, a fourth metatarsal 216, and a fifth metatarsal 218. Themetatarsals are connected distally to phalanges 220 and, moreparticularly, each to a respective proximal phalanx. The firstmetatarsal 210 is connected proximally to a medial cuneiform 222, whilethe second metatarsal 212 is connected proximally to an intermediatecuneiform 224 and the third metatarsal is connected proximally tolateral cuneiform 226. The fourth and fifth metatarsals 216, 218 areconnected proximally to the cuboid bone 228. The joint 230 between ametatarsal and respective cuneiform (e.g., first metatarsal 210 andmedial cuneiform 222) is referred to as the tarsometatarsal (“TMT”)joint. The joint 232 between a metatarsal and respective proximalphalanx is referred to as a metatarsophalangeal joint. The angle 234between adjacent metatarsals (e.g., first metatarsal 210 and secondmetatarsal 212) is referred to as the intermetatarsal angle (“IMA”).

As noted, FIG. 1A is a frontal plane view of foot 200 showing a typicalposition for first metatarsal 210. The frontal plane, which is alsoknown as the coronal plane, is generally considered any vertical planethat divides the body into anterior and posterior sections. On foot 200,the frontal plane is a plane that extends vertically and isperpendicular to an axis extending proximally to distally along thelength of the foot. FIG. 1A shows first metatarsal 210 in a typicalrotational position in the frontal plane. FIG. 1B shows first metatarsal210 with a frontal plane rotational deformity characterized by arotational angle 236 relative to ground, as indicated by line 238.

FIG. 2A is a top view of foot 200 showing a typical position of firstmetatarsal 210 in the transverse plane. The transverse plane, which isalso known as the horizontal plane, axial plane, or transaxial plane, isconsidered any plane that divides the body into superior and inferiorparts. On foot 200, the transverse plane is a plane that extendshorizontally and is perpendicular to an axis extending dorsally toplantarly (top to bottom) across the foot. FIG. 2A shows firstmetatarsal 210 with a typical IMA 234 in the transverse plane. FIG. 2Bshows first metatarsal 210 with a transverse plane rotational deformitycharacterized by a greater IMA caused by the distal end of firstmetatarsal 210 being pivoted medially relative to the second metatarsal212.

FIG. 3A is a side view of foot 200 showing a typical position of firstmetatarsal 210 in the sagittal plane. The sagittal plane is a planeparallel to the sagittal suture which divides the body into right andleft halves. On foot 200, the sagittal plane is a plane that extendsvertically and is perpendicular to an axis extending proximally todistally along the length of the foot. FIG. 3A shows first metatarsal210 with a typical rotational position in the sagittal plane. FIG. 3Bshows first metatarsal 210 with a sagittal plane rotational deformitycharacterized by a rotational angle 240 relative to ground, as indicatedby line 238.

A system and technique that utilizes a compressor-distractor andinstrument defining a sliding surface according to the disclosure can beuseful during a bone positioning procedure, for example, to correct ananatomical misalignment of a bones or bones. In some applications, thecompressor-distractor can help establish and/or maintain a realignmentbetween a metatarsal and an adjacent cuneiform. Additionally oralternatively, the compressor-distractor can facilitate clean-up andcompression between adjacent bone portions between fixation. Theinstrument defining the sliding surface can help facilitate compressionof the bone portions after clean-up, e.g., by helping to prevent thebone portion being compressed from catching or hanging up on adjacenttissue and/or bone during compression, which move the bone portion beingcompressed out of a desired alignment.

The metatarsal undergoing realignment may be anatomically misaligned inthe frontal plane, transverse plane, and/or sagittal plane, asillustrated and discussed with respect to FIGS. 1-3 above. Accordingly,realignment may involve releasing the misaligned metatarsal forrealignment and thereafter realigning the metatarsal in one or moreplanes, two or more planes, or all three planes. After suitablyrealigning the metatarsal, the metatarsal can be fixated to hold andmaintain the realigned positioned.

While a metatarsal can have a variety of anatomically aligned andmisaligned positions, in some examples, the term “anatomically alignedposition” means that an angle of a long axis of first metatarsal 210relative to the long axis of second metatarsal 212 is about 10 degreesor less (e.g., 9 degrees or less) in the transverse plane and/orsagittal plane. In certain embodiments, anatomical misalignment can becorrected in both the transverse plane and the frontal plane. In thetransverse plane, a normal IMA 234 between first metatarsal 210 andsecond metatarsal 212 is less than about 9 degrees. An IMA 234 ofbetween about 9 degrees and about 13 degrees is considered a mildmisalignment of the first metatarsal and the second metatarsal. An IMA234 of greater than about 16 degrees is considered a severe misalignmentof the first metatarsal and the second metatarsal. In some embodiments,methods and/or devices according to the disclosure are utilized toanatomically align first metatarsal 210 by reducing the IMA from over 10degrees to about 10 degrees or less (e.g., to an IMA of 9 degrees orless, or an IMA of about 1-5 degrees), including to negative angles ofabout −5 degrees or until interference with the second metatarsal, bypositioning the first metatarsal at a different angle with respect tothe second metatarsal.

With respect to the frontal plane, a normal first metatarsal will bepositioned such that its crista prominence is generally perpendicular tothe ground and/or its sesamoid bones are generally parallel to theground and positioned under the metatarsal. This position can be definedas a metatarsal rotation of 0 degrees. In a misaligned first metatarsal,the metatarsal may be axially rotated between about 4 degrees to about30 degrees or more. In some embodiments, methods and/or devicesaccording to the disclosure are utilized to anatomically align themetatarsal by reducing the metatarsal rotation from about 4 degrees ormore to less than 4 degrees (e.g., to about 0 to 2 degrees) by rotatingthe metatarsal with respect to the adjacent cuneiform.

A compressor-distractor according to the disclosure may be useful todistract a misaligned metatarsal from an adjacent cuneiform to provideaccess to the end faces of the bones and/or tarsometatarsal joint. Thecompressor-distractor may also be useful to apply a compressive force tothe metatarsal and adjacent cuneiform (e.g., after preparing the endfaces of the bones) to press the bones together to facilitate fixation.Additionally or alternatively, the compressor-distractor may impartand/or maintain relative movement between the metatarsal and adjacentcuneiform, such as rotation and/or pivoting of one bone relative to theother bone. For example, the compressor-distractor may be configuredwith an angular offset between pin-receiving holes, which may beeffective to move the metatarsal from an anatomically misalignedposition to an anatomically aligned position. As thecompressor-distractor is translated over pins inserted into themetatarsal and cuneiform, the angular offset of the pin-receiving holesmay cause the pins to move from being generally parallel to an angularalignment dictated by the pin-receiving holes. The resulting movement ofthe metatarsal relative to cuneiform caused by this movement can helpposition the metatarsal in an aligned position.

In other configurations, however, the compressor-distractor may not movethe metatarsal from an anatomically misaligned position to ananatomically aligned position. Rather, the compressor-distractor may beconfigured to distract and compress a metatarsal relative to an adjacentcuneiform without performing rotating and/or pivoting the metatarsalrelative to an adjacent cuneiform. For example, thecompressor-distractor may have pin-receiving holes that are not angularoffset relative to each other. In these implementations, thecompressor-distractor can be attached and/or removed from the metatarsalrelative and adjacent cuneiform without intended to rotate and/or pivotthe metatarsal relative to the cuneiform.

A variety of different instruments defining sliding surfaces can be usedin the systems and techniques according to the present disclosure.Example instruments that may provide a sliding surface include, but arenot limited to, a surgical pin or rod, a screw driver head/shaft, anosteotome, or a retractor. Depending on the instrument used, theinstrument may have a variety of cross-sectional shapes, such as agenerally polygonal shape (e.g., square, hexagonal), a generally arcuateshape (e.g., circular, elliptical), or combinations of polygonal andarcuate shapes. Example instruments are described in greater detailbelow with respect to FIGS. 8-13 .

An example technique utilizing a compressor-distractor and instrumentproviding a sliding surface will be described in greater detail belowwith respect to FIGS. 16-25 . However, example compressor-distractorconfigurations that may be used according to the disclosure will firstbe described with respect to FIGS. 4-7 .

FIG. 4 is a perspective view of an example compressor-distractor 100that can be used in systems and techniques according to disclosure.Compressor-distractor 100 is illustrated as having a first engagementarm 102 and a second engagement arm 104. Compressor-distractor 100 alsoincludes an actuator 106 that is operably coupled to the firstengagement arm 102 and the second engagement arm 104. Actuator 106 canbe actuated to move the two engagement arms toward each other and awayfrom each other to adjust a separation distance between the two arms.Further, as will be discussed in greater detail, each engagement arm mayinclude at least one pin-receiving hole that is configured to receive apin inserted into a bone.

For example, first engagement arm 102 may include a first pin-receivinghole 108 and second engagement arm 104 may include a secondpin-receiving hole 110. The first pin-receiving hole 108 can receive afirst pin 112, while the second pin-receiving hole 110 can receive asecond pin 114. The first pin 112 and second pin 114 can be insertedinto different bones or bone portions being worked upon. In the case ofa bone realignment procedure, for example, first pin 112 can be insertedinto a metatarsal (e.g., first metatarsal 210) and second pin 114 can beinserted into a cuneiform (e.g., medial cuneiform 222). Thepin-receiving holes can anchor compressor-distractor 100 to the bonesbeing compressed and/or distracted via the pins inserted through theholes and into the underlying bones. In some configurations, thepin-receiving holes can be used to impart relative movement between onebone in which first pin 112 is inserted and another bone in which secondpin 114 is inserted.

For example, first pin-receiving hole 108 and second pin-receiving hole110 may be angled relative to each other at a non-zero degree angle suchthat, when compressor-distractor 100 is inserted over a substantiallyparallel set of pins, the angled receiving holes cause the pins to moverelative to each other to align with the pin-receiving holes. Thedirection and extent of movement imposed by the angled pin-receivingholes of compressor-distractor 100 may vary depending on the desiredsurgical application in which the compressor-distractor is being used.In the case of a misaligned metatarsal, such as a bunion procedure forinstance, the pin-receiving holes may be angled to impart a frontalplane rotation and/or a sagittal plane translation. As a result, whencompressor-distractor 100 is installed over pins position in themetatarsal and adjacent cuneiform, the angled pin-receiving holes maycause the metatarsal to rotate in the frontal plane relative to thecuneiform and/or translate in the sagittal plane (e.g., downwardly orplantarly) to help correct a misalignment of the metatarsal.

FIG. 5 is a frontal plane view of compressor-distractor 100 showing anexample angular offset between first pin-receiving hole 108 and secondpin-receiving hole 110. In this example, the two pin-receiving holes areangled relative to each other in the frontal plane by an angle 116.Angle 116 may be measured between two linear pins (e.g., first pin 112and second pin 114) inserted through respective receiving holes in theperspective of the frontal plane. While the degree of angular offsetbetween first pin-receiving hole 108 and second pin-receiving hole 110may vary, in the case of a metatarsal realignment procedure, angle 116may range from 2° to 20°, such as from 6° to 15°, or from 8° to 12°, orapproximately 10°. The two pin-receiving holes may be offset in adirection that causes the metatarsal to rotate laterally as thecompressor-distractor 100 is installed over first and second pins 112,114. For example, when compressor-distractor 100 is positioned on themedial side of the foot, the first pin-receiving hole 108 may be angledto cause first pin 112 to rotate toward the lateral side of the footrelative to second pin 114.

In addition to or in lieu of providing a fontal plane angulation,compressor-distractor 100 may be configured to impart sagittal planerotation, when the compressor-distractor 100 is installed over first andsecond pins 112, 114. For example, when installed over substantiallyparallel first and second pins 112, 114 positioned in the metatarsal andcuneiform, respectively, the angulation of first and second pin holes108, 110 may cause the metatarsal to rotate or flex plantarly (e.g.,such that the distal end of the metatarsal is rotated plantarly aboutthe TMT joint).

FIG. 6 is a sagittal plane view of compressor-distractor 100 showinganother example angular offset between first pin-receiving hole 108 andsecond pin-receiving hole 110. In this example, the two pin-receivingholes are angled relative to each other in the sagittal plane by anangle 118. Angle 118 may be measured between two linear pins (e.g.,first pin 112 and second pin 114) inserted through respective receivingholes in the perspective of the sagittal plane. While the degree ofangular offset between first pin-receiving hole 108 and secondpin-receiving hole 110 may vary, in the case of a metatarsal realignmentprocedure, angle 118 may range from 5° to 12°, such as from 7° to 10°,or from 8 to 9°, or approximately 8.5°. The two pin-receiving holes maybe offset in a direction that causes the metatarsal to rotate (e.g.,downwardly or plantarly) in the sagittal plane as thecompressor-distractor 100 is installed over first and second pins 112,114.

In general, features described as pin-receiving holes may be void spacesextending linearly through the body of compressor-distractor 100 andconfigured (e.g., sized and/or shaped) to pass a pin inserted into abone therethrough. While the pin-receiving holes may have any polygonal(e.g., square, rectangle) or arcuate (e.g., curved, elliptical) shape,the pin-receiving holes may typically have a circular cross-sectionalshape. In some examples, the pin-receiving holes have a diameter rangingfrom 0.1 mm to 10 mm, such as from 0.5 mm to 4 mm. The pin-receivingholes may have a length (e.g., extending through the thickness of firstengagement arm 102 or second engagement arm 104) ranging from 5 mm to 50mm, such as from 10 mm to 25 mm.

Compressor-distractor 100 can have any suitable number of pin-receivingholes. In general, providing multiple pin-receiving holes on each sideof the compressor-distractor 100 may be useful to provide alternativeangulation or movement options for the clinician using thecompressor-distractor. For example, compressor-distractor 100 may have aplurality of pin-receiving holes for use with first pin 112 and/orsecond pin 114. During a surgical procedure, the clinician may select acertain pin-receiving hole from the plurality of pin-receiving holesinto which first pin 112 and/or second pin 114 are to be inserted. Theclinician may select the pin-receiving hole combination based on theamount and direction of movement the clinician desires the first bone tomove relative to the second bone upon installing thecompressor-distractor over first and second pins 112, 114. Afterselecting the desired pin-receiving hole combination, the clinician candirect the distal end of first and second pins 112, 114 into thecorresponding selected pin-receiving holes then translatecompressor-distractor 100 from the distal end of the pins down towardsthe proximal end of the pins.

It should be appreciated that while compressor-distractor 100 may havemultiple pin-receiving holes for first pin 112 and/or second pin 114,the disclosure is not limited in this respect. In other configurations,compressor-distractor 100 may only have a single pin-receiving hole intowhich first pin 112 and/or second pin 114 can be inserted. In stillother configurations, compressor-distractor 100 may have one or morepin-receiving hole(s) that rotate and/or slide within one or more slotsto provide adjustable angulation, allowing the clinician to adjust theangular alignment of first and/or second pin-receiving holes 108, 110.

In the example of FIG. 4 , compressor-distractor 100 is illustrated ashaving two pin-receiving holes associated with first pin 112 and twopin-receiving holes associated with second pin 114. In particular, FIG.4 illustrates first engagement arm 102 as having previously-describedfirst pin-receiving hole 108 and second engagement arm 104 as havingpreviously-described second pin-receiving hole 110. In addition, firstengagement arm 102 is illustrated has having a third pin-receiving hole120, while second engagement arm 104 has a fourth pin-receiving hole122. First and second engagement arms 102, 104 may each have fewerpin-receiving holes (e.g., one) or more pin-receiving holes (e.g.,three, four, or more).

In some configurations, the third pin-receiving hole 120 is angledrelative to the fourth pin-receiving hole 122 at a non-zero-degree anglein a second plane different than a first plane in which firstpin-receiving hole 108 is angled relative to second pin-receiving hole110. For example, first pin-receiving hole 108 may be angled relative tosecond pin-receiving hole 110 in the frontal plane and/or sagittalplane. Third pin-receiving hole 120 may be parallel to secondpin-receiving hole 110 in the frontal plane but angled relative to thesecond pin-receiving hole in the sagittal plane. Further, fourthpin-receiving hole 122 may be parallel to first pin-receiving hole 108in the frontal plane but angled relative to the first pin-receiving holein the sagittal plane. Third and fourth pin-receiving holes 120, 122 canbe angled relative to each other and/or first and second pin-receivingholes 108, 110 at any of the angles discussed above. When configured asillustrated in FIG. 4 , a clinician desiring both frontal plane andsagittal plane movement can use the first and second pin holes 108, 110.By contrast, when the clinician desires sagittal plane movement but notfrontal plane movement, the clinician can use first and fourthpin-receiving hole 108, 122.

As briefly discussed above, compressor-distractor 100 can open and closeto compress and distract the bones to which to the compressor-distractoris secured. To facilitate movement, compressor-distractor 100 isillustrated as having an actuator 106. Actuator 106 is configured tocontrol movement of first engagement arm 102 relative to secondengagement arm 104. Actuator 106 may be implemented using any featurethat provides controllable relative movement between the two engagementarms, such as rotary movement, sliding movement, or other relativetranslation. In some configurations, actuator 106 is configured to movefirst and second engagement arms 102, 104 at least 1 mm away from eachother, such as a distance ranging from 1 mm to 45 mm, a distance rangingfrom 1 mm to 5 mm, or a distance ranging from 1 mm to 2.5 mm duringdistraction. Actuator 106 may be actuated during compression until thefaces of the bones to which compressor-distractor 100 is attached aresuitably compressed and/or the sidewall faces of first and secondengagement arms 102, 104 contact each other.

In the example of FIG. 4 , actuator 106 is illustrated as including ashaft 124 connected to the first engagement arm 102 and the secondengagement arm 104. Shaft 124 may be threaded and actuator 106 mayfurther include a knob 126 coupled to the shaft. Rotation of knob 126 inone direction may cause first engagement arm 102 to move closer tosecond engagement arm 104, while rotation of the knob in the oppositedirection can cause the first engagement arm to move away from thesecond engagement arm.

To secure actuator 106 to compressor-distractor 100, the actuator may befixedly connected to one of the arms. For example, shaft 124 of actuator106 may be fixedly attached along its length to first engagement arm 102and rotatable relative to the arm. As a result, when knob 126 isrotated, second engagement arm 104 may move along the length of shaft124 towards and/or away from first engagement arm 102. This providesrelative movement between the two arms while first engagement arm 102remains in a fixed position relative to actuator 106.

In FIG. 4 , first engagement arm 102 is illustrated as extending from adistal end 128A to a proximal end 128B. Similarly, second engagement arm104 is illustrated as extending from a distal end 130A to a proximal end130B. Actuator 106 is positioned adjacent the proximal ends 128B, 130Bof the first and second engagement arms 102, 104, respectively, such asthe proximal half of the arms in the illustrated configuration.Offsetting actuator 106 from the pin-receiving holes may be useful, forexample, to provide clearance for the clinician to manipulate theactuator when compressor-distractor 100 is inserted on pins installed inbones. In the case of a foot surgery, first and second engagement arms102, 104 may have a length affective to position actuator 106 to beoffset medially from the foot being operated on while firstpin-receiving hole 108 is engaged with a first pin 112 inserted into ametatarsal and second pin-receiving hole 110 is engaged with a secondpin 114 engaged with a cuneiform.

To help stabilize first engagement arm 102 relative to second engagementarm 104 during movement along shaft 124, compressor-distractor 100 mayalso include one or more unthreaded shafts extending parallel to thethreaded shaft. In FIG. 4 , for example, actuator 106 has a firstunthreaded shaft 132A and a second unthreaded shaft 132B (collectivelyreferred to as “unthreaded shaft 132”). Unthreaded shaft 132 extendsparallel to threaded shaft 124 and helps stabilize second engagement arm104 as it moves along the threaded shaft towards and away from firstengagement arm 102. Threaded shaft 124 is illustrated as extendingthrough a threaded aperture in the sidewall of second engagement arm102, while unthreaded shaft 132 is illustrated as extending through anunthreaded aperture in the sidewall of the engagement arm.

First engagement arm 102 and second engagement arm 104 can have avariety of different sizes and shapes. In general, each engagement armmay define a length offsetting the pin-receiving holes from actuator106. In some examples, distal end 128A of first engagement arm 102defines a first pin block 134 and/or distal end 130A of secondengagement arm 104 defines a second pin block 136. The pin blocks may beregions of the respective engagement arms defining pin-receiving holesand through which the pin-receiving holes extend. First and second pinblocks 134, 136 may have a thickness greater than a thickness of theremainder of the engagement arms. For example, as shown, pin blocks 134,136 may extend downwardly (e.g., plantarly) from a remainder of theengagement arms and/or actuator 106.

In FIG. 4 , first engagement arm 102 is illustrated as having a samelength as second engagement arm 104. As a result, distal end 128A of thefirst engagement arm is parallel with the distal end 130A of the secondengagement arm. In other configurations, one engagement arm may belonger than the other engagement arm to provide an offset. For example,first engagement arm 102 may be longer than second engagement arm 104,e.g., causing the first engagement arm to extend farther laterally whenapplied to a foot being operated upon than second engagement arm 104.This configuration may be useful during bunion correction procedures toimpart transverse plane movement (e.g., rotation) of the metatarsalrelative to the cuneiform to close the IM angle.

Compressor-distractor 100 may be fabricated from any suitable materialor combination of materials, such as metal (e.g., stainless steel)and/or polymeric materials. In some configurations,compressor-distractor 100 is fabricated from a radiolucent material suchthat it is relatively penetrable by X-rays and other forms of radiation,such as thermoplastics and carbon-fiber materials. Such materials areuseful for not obstructing visualization of bones using an imagingdevice when the bone positioning guide is positioned on bones.

Compressor-distractor 100 can have a variety of differentconfigurations, and a compressor-distractor according to the disclosureis not limited to the example configuration illustrated with respect toFIGS. 3-6 . For example, FIG. 7 illustrates a side view of analternative configuration of compressor-distractor 100 in which firstengagement arm 102 and second engagement arm 104 are curved upwardlyaway from first and second pin blocks 134, 136. The curvature of thearms can position actuator 106 out of the surgical site, removing avisual obstruction to help the clinician perform the surgical technique.

As mentioned above, a compressor-distractor according to someimplementations of the disclosure may not be configured with angledpin-receiving holes and/or may have parallel pin-receiving holes thatare utilized in lieu of angled pin-receiving holes also presented on thecompressor-distractor. FIG. 7 is a perspective illustration of anotherexample configuration of compressor-distractor 100 deployed in anexample surgical technique attached to foot 200. Like reference numeralsin FIG. 7 reference to like elements discussed above with respect toFIGS. 1-6 .

Some example systems and techniques according to the present disclosuremay utilize an instrument defining a sliding surface, which can bepositioned between a bone being moved (e.g., first metatarsal) and anadjacent stationary bone (e.g., second metatarsal). In general, anysuitable mechanical instrument that maintains a spacing between adjacentbones and provides a surface along which a bone can translate be used asthe instrument defining the sliding surface according to the disclosure.

FIG. 8 is a perspective view of one example instrument that can be usedas an instrument defining a sliding surface. In this instrument,instrument 300 has a generally rectangular shape and tapers in thicknessalong at least a portion of the length from the trailing end 302 to theleading end 304. Instrument 300 defines a first major face 306 and asecond major face 308 opposite the first major face. One or both offirst major face 306 and second major face 308 may provide a slidingsurface along a bone being moved can slide during performance of a bonerealignment procedure.

Instrument 300 may be sized sufficiently small (e.g., in thickness) sothat it can be positioned between a bone being moved (e.g., firstmetatarsal) and an adjacent stationary bone (e.g., second metatarsal).In some implementations, the clinician is provided a system containingmultiple different size and/or shape instruments defining slidingsurfaces and allowed to choose the specific size and/or shape instrumentdesired for the specific procedure being performed. FIG. 9 illustratesan example kit or system of different sized instruments defining asliding surface, labeled with exemplary “width×thickness” sizes, thatmay be provided to a clinician in such an embodiment. In some examples,the instrument defining the sliding surface has a width ranging from 5millimeters to 15 millimeters (e.g., about 6 millimeters to about 10millimeters) and a thickness ranging 1 millimeter to 12 millimeters(e.g., about 2 millimeters to about 3 millimeters), although instrumentshaving different dimensions can be used.

The instrument 300 defining the sliding surface can have a variety ofdifferent configurations. FIGS. 10A and 10B illustrate another exampleconfiguration of instrument 300 that can be used according to thedisclosure. FIG. 10A is a perspective view of one side of instrument300, while FIG. 10B is a perspective view of the instrument from theopposite side. In the illustrated configuration, instrument 300 includesa body 380 and a handle 382 operatively connected to the body.Typically, body 380 and handle 382 will be formed as a unitarystructure, e.g., by milling, casting, or molding the components to bepermanently and structurally integrated together. However, body 380 andhandle 382 may be fabricated as separate components that aresubsequently joined together.

Body 380 can be configured (e.g., sized and shaped) to be inserted intoan intermetatarsal space between adjacent metatarsals. For example, body380 may be configured to be inserted between a first metatarsal and asecond metatarsal. Body 380 is illustrated as having a rectangular shapewith a length 383 greater than its width 384 and thickness 386.Moreover, in this configuration, body 380 has a constant width 384across its length but has a thickness 386 that that tapers along atleast a portion of the length from the leading end 388 to the trailingend 390. For example, body 380 may have a tapered leading end 388 tofacilitate insertion of instrument 300 in a space between adjacentmetatarsals. In other configurations, body 380 may have a constantthickness across is length or may define a different generally polygonalshape (e.g., square, hexagonal) and/or generally arcuate shape (e.g.,circular, elliptical).

Instrument 300 in FIGS. 10A and 10B includes handle 382. Handle 382 canproject angularly away from body 380 to define a tissue retraction space392. Tissue retraction space 392 may be a region bounded on one side bybody 380 and one or more other sides by handle 382. In use, instrument300 may be inserted into an intermetatarsal space with handle 382extending out of the surgical incision and over an epidermal layer withtissue captured in tissue retraction space 392. For example, instrument300 may be inserted into an intermetatarsal space with handle 382projecting toward the lateral side of the foot being operated upon.Tissue retraction space 392 may help retract tissue and push the tissuelaterally away from a first metatarsal and/or medial cuneiform beingoperated upon.

In the illustrated example, handle 382 is illustrated as projectinglaterally at a non-zero-degree angle away from body 380. The specificangular orientation of the handle 382 relative to the body 380 may vary.However, in some examples, handle 382 is oriented relative to the body380 so a handle axis 393 intersects an axis 394 extending along thelength of the body at an acute angle 396 ranging from 20 degrees to 75degrees, such as 35 degrees to 55 degrees. Moreover, handle 382 may becomposed of a single linear portion that intersects body 380 at aspecific angular orientation or may be composed of multiple linearportions oriented at different angles relative to each other.

In the illustrated example, handle 382 includes a grip portion 398 and ahandle body 402. The grip portion 398 can provide a surface that aclinician physically grips to insert instrument 300 into anintermetatarsal space. For example, grip portion 398 may containknurling or other anti-friction surfacing texturing to allow theclinician to help grip the fulcrum. Handle body 402 may be positionedbetween the body 380 of instrument 300 and grip portion 398. Handle body402 may or may not have a reduced cross-sectional width compared to body380 and/or grip portion 398, as illustrated.

When configured with grip portion 398, the grip portion can be co-linearwith handle body 402 or may be offset relative to the handle body. Whengrip portion 398 is offset from handle body 402, a grip axis 404extending along the length of the grip portion may intersect the handleaxis 393 at an acute ranging from 20 degrees to 75 degrees, such as 35degrees to 55 degrees, although other angular arrangements can also beused. In the illustrated configuration, grip axis 404 is perpendicularto the axis 394 defined by body 380. Accordingly, when inserted into anintermetatarsal space, retracted tissue may be bounded by alaterally-facing side of body 380, by the lower surface of grip portion398, and in the dorsal-lateral direction by handle portion 392.

In some examples, the bone-contacting faces of body 380 are configuredto inhibit and/or facilitate relative motion between a bone and therespective bone-contacting face. With reference to FIG. 10A, body 380 ofinstrument 300 has a first face 410, which may be positioned in contactwith a first metatarsal. First face 410 may provide a sliding surfaceagainst which the metatarsal can contact and slide against duringtranslation. Accordingly, first face 410 may have surface features whichallow the contacting metatarsal (e.g., first metatarsal) to translateand slide against during movement from a distal to proximal direction.The surface features may be implemented as directionally-oriented ribsand/or grooves.

For example, FIG. 11 is perspective view of the second face 412 ofinstrument 300 showing an example arrangement of surface features thatmay be used to facilitate distal to proximal axial translation of themetatarsal, e.g., while inhibiting plantar or dorsal movement. Byorienting the grooves widthwise, the edges of the grooves may have atendency to engage or bite into the metatarsal if the metatarsal ismoved plantarly or dorsally, thereby inhibiting such movement, whileallowing the metatarsal to move distally and/or proximally. It should beappreciated, however, that a slide surface of instrument 300 may have adifferent configuration of surface features (e.g., even ones thatgenerally inhibit movement) or may not have any surface features.

With further reference to FIG. 10B, body 380 may have different surfacefeatures on the opposite face from first face 410. For example, body 380of instrument 300 has a second face 412 that is opposite first face 410.Second face 412 may have surface features that inhibit movement betweeninstrument 300 and the contacting metatarsal (e.g., second metatarsal)in the dorsal-to-plantar direction. The surface features may beimplemented as directionally-oriented ribs and/or grooves. For example,in FIG. 10B, second face 412 is illustrated as having knurling, or aseries of intersecting and overlapping ridges.

In the configuration of FIGS. 10A and 10B, handle 382 includes gripportion 398 that can provide a surface a clinician physically grips toinsert instrument 300. In other configurations, handle 382 may beimplemented using a second instrument body that is a different sizeand/or shape than body 380. This arrangement can provide a clinicianwith a single instrument having two functional ends, either one of whichcan be selected and used by the clinician, e.g., depending on thecharacteristics of the patient undergoing a surgical procedure.

FIGS. 12A and 12B are perspective and side views, respectively, of suchan example instrument 300 having two bodies defining sliding surfaces.As shown in this example, instrument 300 includes the body 380 and thehandle 382 projecting at a non-zero-degree angle away from the body. Thebody 380 provides a first body defining a sliding surface and configured(e.g., sized and/or shaped) to be inserted into an intermetatarsalspace. In addition, handle 382 in this example is defined at least inpart by a second body 420. The second body 420 defining a slidingsurface may also be configured (e.g., sized and/or shaped) to beinserted into an intermetatarsal space. The first body 380 can differfrom the second body 420 by having a different size and/or shape.

In FIGS. 12A and 12B, the first body 380 and the second body 420 areshown as having the same shape but different sizes. In particular, firstbody 380 has a length 383, a thickness 386, and a width orthogonal tothe length and thickness. Further, the second body 420 has a length 422,a thickness 424, and a width orthogonal to the length and thickness. Thethickness 422 of the second body 420 is illustrated as being greaterthan the thickness 386 of the first body 380. The length and width ofthe first and second bodies 380, 420 are illustrated as being the samebut may be different in other examples (e.g., different width with samelength, different length but same width, or different length and width).

In general, configuring the first body 380 and second body 420 withdifferent thicknesses can be useful to facilitate use in different sizedintermetatarsal spaces. For example, the clinician may select one sizedbody over the other sized body based on the anatomy (e.g.,intermetatarsal space sizing) of the patient undergoing a surgicalprocedure. If the clinician determines upon beginning to insert theselected instrument body that the selected body is inappropriatelysized, the clinician may retract the instrument, flip the instrument,and insert the body on the opposite side of the instrument.

While the first body 380 and second body 420 can be configured with avariety of different sizes, in some examples, each body has a thicknessranging from 0.5 millimeters to 12 millimeters, such as from 1millimeter to 10 millimeters, or from 1 millimeter to 5 millimeters. Thethickness 424 of the second body 420 may be at least 0.2 millimetersthicker than the thickness 386 of the first body, such as at least 0.5millimeters thicker, at least 1 millimeter thicker, or at least 2millimeters thicker. In some examples, first body 380 and second body420 each have a width within a range from 5 millimeters to 15millimeters (e.g., about 6 millimeters to about 10 millimeters) and alength ranging from 10 millimeters to 30 millimeters, although otherdimensions can be used.

In the illustrated example of FIGS. 12A and 12B, the first body 380 hasa leading end 388 and a trailing end 390 and the second body 420 has aleading end 426 and a trailing end 428. In some examples as shown, theleading end 388 of the first body 380 and/or the leading end 426 of thesecond body 420 has a thickness that tapers adjacent the leading end.This configuration can be useful to facilitate insertion of aninstrument body into an intermetatarsal space. When configured with atapered leading end, the exemplary thickness ranges discussed above maybe measured as the maximum thickness of the body at any location alongthe length of the body.

In the illustrated example, first body 380 and second body 420 areoriented at a non-zero degree relative to each other and separated by ahandle body 402, e.g., of lesser cross-sectional width. For example, asdiscussed with respect to FIGS. 10A and 10B, handle 382 may be orientedrelative to first body 380 such that handle axis 393 intersects an axis394 extending along the length of the body at an acute angle 396. Whenhandle 382 includes the handle body 402 and the second body 420, thesecond body can be co-linear with handle body 402 or may be offsetrelative to the handle body. For example, an axis 404 extending alongthe length of the second body may intersect the handle axis 393 at anacute angle 406 ranging from 20 degrees to 75 degrees, such as 35degrees to 55 degrees, as discussed above.

In yet other configurations where instrument 300 is configured withmultiple ends of different dimensions, the ends may or may not beseparated by a separate handle body 402. For example, first body 380 andsecond body 420 may be formed as a unitary structure (e.g., as opposedends of a linear or curved unitary body).

FIGS. 13A and 13B are perspective and side views, respectively, of anexample multidimensional instrument defining a sliding surface havingends of different dimensions. As shown, instrument 300 is composed offirst body 380 and second body 420 as discussed above with respect toFIGS. 12A and 12B. In the configuration illustrated in FIGS. 13A and13B, however, the first body 380 and the second body 420 are integratedtogether to form a unitary instrument having two opposed ends ofdifferent dimensions, either of which can be inserted into anintermetatarsal space to provide a sliding surface. As illustrated, theunitary instrument body has a generally rectangular shape such thatopposed ends of the instrument are separated by a linear length of thebody. However, the body may be curved or non-linear in alternativeconfigurations. As discussed above, the first body 380 and the secondbody 420 forming the respective portions of the unitary body can have avariety of different dimensions, and may or may not have surfacefeatures, to provide a clinician with a variety of sliding surfaceoptions in a single instrument.

A system that includes a compressor-distractor and instrument defining asliding surface according to the disclosure may be used as part of asurgical procedure in which at least two pins are inserted intodifferent bones or different portions of the same bone. The at least twopins may be inserted in generally parallel alignment and/or the pins maybe realigned during the surgical procedure so as to be substantiallyparallel (e.g., prior to installation of compressor-distractor 100). Thetwo pins may be substantially parallel in that the pins are positionedside-by-side and have substantially the same distance continuouslybetween the two pins in each of the three planes (e.g., the distancevaries by less than 10%, such as less than 5% across the lengths of thepins in any given plane, with different continuous distances indifferent planes). Compressor-distractor 100 can be inserted over theparallel pins by threading the parallel pins into the pin-receivingholes of the device. If the pin-receiving holes of compressor-distractor100 are parallel, the compressor-distractor can be inserted over thepins without changing the position of the pins. By contract, if thepin-receiving holes of compressor-distractor 100 are angled, insertingthe compressor-distractor over the pins can cause the pins to move froma substantially parallel alignment to an angled alignment dictated bythe angulation of the pin-receiving holes.

In either case, compressor-distractor 100 may then be used to distractthe bone portions into which the pins are inserted (e.g., by actuatingactuator 106 to draw the bone portions away from each other) and/orcompress the bone portions into which the pins are inserted (e.g., byactuating actuator 106 to move the bone portions towards each other).Instrument 300 can be positioned between a bone portion being compressed(e.g., a distracted metatarsal) and an adjacent stationary bone (e.g., alateral-most metatarsal to the distracted metatarsal).Compressor-distractor 100 can compress two separated bone portionstoward and/or against each other, e.g., causing the distracted boneportion to translate against the surface of instrument 300.

In some examples, compressor-distractor 100 and instrument 300 is usedas part of a metatarsal realignment procedure in which a metatarsal isrealigned relative to an adjacent cuneiform and/or metatarsal in one ormore planes, such as two or three planes. Additional details on examplebone realignment techniques and devices with which compressor-distractor100 and instrument 300 may be used are described in U.S. Pat. No.9,622,805, titled “BONE POSITIONING AND PREPARING GUIDE SYSTEMS ANDMETHODS,” filed on Dec. 28, 2015 and issued Apr. 18, 2017, and U.S. Pat.No. 9,936,994, titled “BONE POSITIONING GUIDE,” filed on Jul. 14, 2016and issued on Apr. 10, 2018, and US Patent Publication No. 2017/0042599titled “TARSAL-METATARSAL JOINT PROCEDURE UTILIZING FULCRUM,” filed onAug. 14, 2016. The entire contents of each of these documents are herebyincorporated by reference.

The pins over which compressor-distractor 100 is installed may be usedto pin and/or guide another medical instrument used during the surgicaltechnique. For example first and second pins 112, 114 may be used to pina first medical instrument to the bones or bone portions being operatedupon. The medical instrument can be removed over the parallel pins,leaving the pins inserted into the bone or bone portions, andcompressor-distractor 100 subsequently placed over the pins.

For example, in the case of a metatarsal realignment procedure, firstand second pins 112, 114 may be used to pin a bone preparation guide toa foot being operated upon. The bone preparation guide can be used toprepare an end face of a metatarsal and an adjacent end face of acorresponding cuneiform. The bone preparation guide can be taken off thefirst and second pins and compressor-distractor 100 installed on thepins. Compressor-distractor 100 can be manipulated to open the jointspace between the metatarsal and cuneiform, e.g., to facilitate jointcleanup, and/or manipulated to compress the two bones together forfixation.

FIG. 14 illustrates an example bone preparation guide 150 that may beused as part of a surgical procedure involving compressor-distractor 100and instrument 300. In some examples, bone preparation guide 150includes a body 154 defining a first guide surface 160 to define a firstpreparing plane and a second guide surface 164 to define a secondpreparing plane. A tissue removing instrument (e.g., a saw, rotary bur,osteotome, etc., not shown) can be aligned with the surfaces to removetissue (e.g., remove cartilage or bone and/or make cuts to bone). Thefirst and second guide surfaces 160, 164 can be spaced from each otherby a distance, (e.g., between about 2 millimeters and about 10millimeters, such as between about 4 and about 7 millimeters). In theembodiment shown, the first and second guide surfaces are parallel, suchthat cuts to adjacent bones using the guide surfaces will be generallyparallel.

In some configurations, as shown in FIG. 14 , a first facing surface 166is positioned adjacent the first guide surface 160 and/or a secondfacing surface 168 is positioned adjacent the second guide surface 164.In such configurations, the distance between the first guide surface andthe first facing surface defines a first guide slot, and the distancebetween the second guide surface and the second facing surface defines asecond guide slot. Each slot can be sized to receive a tissue removinginstrument to prepare the bone ends. The first and second slots may beparallel or skewed. In the illustrated example, the facing surfaces eachcontain a gap, such that the surface is not a single, continuoussurface. In other embodiments, the facing surfaces can be a single,continuous surface lacking any such gap.

An opening 170 can be defined by the body 154 between the first andsecond guide surfaces. The opening can be an area between the guidesurfaces useful for allowing a practitioner to have a visual path tobones during bone preparation and/or to receive instruments. In theconfiguration shown, the opening extends across the body and a distancefrom a surface 172 opposite of the first facing surface 166 to a surface174 opposite of the second facing surface 168.

The illustrated bone preparation guide also includes a first end 176extending from the body 154 in a first direction and a second end 178extending from the body in a second direction. The second direction canbe different than the first direction (e.g., an opposite direction). Asshown, each of the first end and the second end can include at least onefixation aperture 180 configured to receive a fixation pin to secure thebone preparation guide to an underlying bone. For example, first end 176of bone preparation guide 150 may define a first fixation aperturethrough which first pin 112 (FIG. 4 ) is inserted and the second and 178of bone preparation guide 150 may define a second fixation aperturethrough which second pin 114 (FIG. 4 ) is inserted. These two fixationapertures may be parallel aligned, such that first and second pins 112,114 extend through the holes parallel to each other. The first end 176and/or the second end 178 of bone preparation guide 150 may also definedone or more additional fixation apertures that are angled (at anon-zero-degree angle) or otherwise skewed relative to the two parallelfixation apertures.

In use, a clinician may insert the two parallel pins through fixationapertures 180 and may optionally insert one or more angled pins throughthe one or more angled fixation apertures. This combination of paralleland angled pins may prevent bone preparation guide 150 from beingremoved from the underlying bones being worked upon. When the clinicianhas completed using the bone preparation guide, the angled pin or pinsmay be removed leaving the two parallel pins inserted into theunderlying bones. Bone preparation guide 150 can be slid or otherwisemoved up and off the parallel pins and compressor-distractor 100thereafter inserted down over the pins.

In some examples as shown in FIG. 14 , bone preparation guide 150 canalso include a first adjustable stabilization member 182 engaged withthe first end 176 and/or a second adjustable stabilization member 184engaged with the second end 178. Each of the members can be threaded andengage a threaded aperture defined by the ends. The elevation of eachend can be adjusted with respect to a bone by adjusting thestabilization member. In some embodiments, as shown, the stabilizationmembers are cannulated such that they can receive a fixation pin.

With reference to FIG. 15 , bone preparation guide 150 may include or beused with a spacer 188 that extends downward from the body 154. Spacer188 may be configured to be placed into a joint (e.g., within the TMTjoint). In some embodiments, the spacer 188 is selectively engageablewith the body of the bone preparation guide and removable therefrom. Thespacer can have a first portion 190 configured to extend into a jointspace and a second portion 192 engageable with the body 154. In theembodiment shown, the spacer can be received within opening 170, suchthat the spacer extends from the body in between the first and secondguide surfaces. Such a spacer can be useful for positioning the body ata desired position with respect to a joint and for properly positioningthe guide with respect to bones to be cut in more than one plane (e.g.,three planes selected from more than one of a frontal plane, atransverse plane, and a sagittal plane). The distance between the spacerand the first guide surface can define a length of tissue removal (e.g.,bone or cartilage to be cut) from a first bone, and the distance betweenthe spacer and the second guide surface can define a length of tissueremoval (e.g., bone or cartilage to be cut) from a second bone.

As also shown in FIG. 15 , bone preparation guide 150 may include or beused with a tissue removal location check member 194. Tissue removalcheck member 194 may be engageable with the body 154 and configured toextend to a first bone and a second bone. The tissue removal locationcheck member can have a first portion 196 configured to extend intocontact with first and second bones and a second portion 198 engageablewith the body. In the embodiment shown, the tissue removal check member194 is configured to extend in the body 154 at both the first and secondguiding surfaces. The tissue removal location check member 194 may beuseful for allowing a practitioner to see where a tissue removinginstrument guided by the surfaces will contact the bone to be prepared.

Bone preparation facilitated by bone preparation guide 150 can beuseful, for instance, to facilitate contact between leading edges ofadjacent bones, separated by a joint, or different portions of a singlebone, separated by a fracture, such as in a bone alignment and/or fusionprocedure. A bone may be prepared using one or more bone preparationtechniques. In some applications, a bone is prepared by cutting thebone. The bone may be cut transversely to establish a new bone endfacing an opposing bone portion. Additionally or alternatively, the bonemay be prepared by morselizing an end of the bone. The bone end can bemorselized using any suitable tool, such as a rotary bur, osteotome, ordrill. The bone end may be morselized by masticating, fenestrating,crushing, pulping, and/or breaking the bone end into smaller bits tofacilitate deformable contact with an opposing bone portion.

During a surgical technique utilizing compressor-distractor 100 andinstrument 300, a bone may be moved from an anatomically misalignedposition to an anatomically aligned position with respect to anotherbone. Further, both the end of the moved bone and the facing end of anadjacent end may be prepared for fixation. In some applications, the endof at least one of the moved bone and/or the other bone is preparedafter moving the bone into the aligned position. In other applications,the end of at least one of the moved bone and/or the other bone isprepared before moving the bone into the aligned position.

Movement of one bone relative to another bone can be accomplished usingone or more instruments and/or techniques. In some examples, bonemovement is accomplished using a bone positioning device that applies aforce to one bone at a single location, such that the bone bothtranslates and rotates in response to the force. This may beaccomplished, for example, using a bone positioning guide that includesa bone engagement member, a tip, a mechanism to urge the bone engagementmember and the tip towards each other, and an actuator to actuate themechanism. Additionally or alternatively, bone movement may beaccomplished using compressor-distractor 100 by imparting movement toone bone relative to another bone as the compressor-distractor ispositioned on substantially parallel pins, causing the pins to move outof their substantially parallel alignment and resulting in movement ofthe underlying bones in one plane (e.g., frontal plane, sagittal plane,transverse plane), two or more planes, or all three planes. As yet afurther addition or alternative, a clinician may facilitate movement byphysically grasping a bone, either through direct contact with the boneor indirectly (e.g., by inserting a K-wire, grasping with a tenaculum,or the like), and moving his hand to move the bone.

Regardless of the how movement is accomplished, a surgical technique mayor may not utilize a fulcrum. A fulcrum may provide a structure aboutwhich rotation and/or pivoting of one bone relative to another boneoccurs. The fulcrum can establish and/or maintain space between adjacentbones being moved, preventing lateral translation or base shift of thebones during rotation and/or pivoting. For example, to help avoid theproximal-most base of the first metatarsal 210 from shifting toward theproximal-most base of the second metatarsal 212, a clinician can insertthe fulcrum in the notch between first metatarsal 210 and secondmetatarsal 212 at the base of the metatarsals (e.g., adjacent respectivecuneiform) before moving the first metatarsal. The fulcrum can provide apoint about which first metatarsal 210 can rotate and/or pivot whilehelping minimize or avoid base compression between the first metatarsaland the second metatarsal. In addition, use of the fulcrum may causefirst metatarsal 210 and medial cuneiform 222 to be better angledrelative to guide slots positioned over the end faces of the bones,providing a better cut angle through the guide slots than without use ofthe fulcrum. This can help reduce or eliminate unwanted spring-back, orreturn positioning, of first metatarsal 210 after initial realignment ofthe metatarsal.

When the surgical technique is implemented using a fulcrum, the fulcrummay be the same instrument or a different instrument than instrument 300defining a sliding surface. For example, in some implementations,instrument 300 is utilized as a fulcrum about which a proximal portionof one bone portion (e.g., first metatarsal) is rotated to close anangle with an adjacent bone portion (e.g., an IMA with a secondmetatarsal). The same instrument 300 can further be utilized in the sameprocedure to provide a sliding surface against which the one boneportion (e.g., first metatarsal) is moved relative to another boneportion (e.g., medial cuneiform), such as by translating the boneportion generally axially in a distal to proximal direction within thesagittal plane.

When used, the clinician can insert the fulcrum between first metatarsal210 and second metatarsal 212 (or other adjacent bones, when notperforming a metatarsal realignment) at any time prior to moving thefirst metatarsal (e.g., by actuating a bone positioning guide orotherwise manipulating the bone). In different embodiments, the fulcrumcan be inserted between first metatarsal 210 and second metatarsal 212before or after inserting joint spacer 188 and/or placing bonepreparation guide 150 over the joint being operated upon. In oneembodiment, the clinician prepares the joint being operated upon torelease soft tissues and/or excise the plantar flare from the base ofthe first metatarsal 210. Either before or after installing an optionalbone positioning guide over adjacent bones, the clinician inserts thefulcrum at the joint between the first metatarsal and the secondmetatarsal. The clinician can subsequently actuate bone positioningguide 10 (e.g., when used). As distal portion of first metatarsal canmove toward the second metatarsal in the transverse plane to close theIMA, thereby pivoting a proximal portion of the first metatarsal aboutthe fulcrum and reducing the IMA between the first metatarsal and thesecond metatarsal. While use of a fulcrum can minimize or eliminate basecompression between adjacent bones being operated upon, in otherembodiments, the described systems and techniques can be implementedwithout using a fulcrum.

An example method for preforming a bone alignment procedure utilizing acompressor-distractor and instrument defining a sliding surfaceaccording to the disclosure will now be described with respect to FIGS.16-25 depicting a foot 200 having a first metatarsal 210, a medialcuneiform 222, and a second metatarsal 212. Unless otherwise indicated,the example steps described can be carried out in any order and need notbe performed in the order described.

After customary surgical preparation and access, a bone preparationinstrument 296 can be inserted into the joint (e.g., firsttarsal-metatarsal joint) to release soft tissues and/or excise theplantar flare from the base of the first metatarsal 210, as shown inFIG. 16 . Excising the plantar flare may involve cutting plantar flareoff the first metatarsal 210 so the face of the first metatarsal isgenerally planar. This step helps to mobilize the joint to facilitate adeformity correction. In some embodiments, the dorsal-lateral flare ofthe first metatarsal may also be excised to create space for thedeformity correction (e.g., with respect to rotation of the firstmetatarsal). In certain embodiments, a portion of the metatarsal basefacing the medial cuneiform can be removed during this mobilizing step.

An incision can be made and, if a bone positioning instrument is goingto be used, a tip 50 of a bone positioning guide 10 inserted on thelateral side of a metatarsal other than the first metatarsal 210, suchas the second metatarsal 212. As shown in FIG. 17 , the tip can bepositioned proximally at a base of the second metatarsal 212 and a thirdmetatarsal 294 interface. A surface of a bone engagement member 40 canbe placed on the proximal portion of the first metatarsal 210. In someembodiments, the bone engagement member engages a medial ridge of thefirst metatarsal 210. As shown, the body 20 of the positioning guide canbe generally perpendicular to the long axis of the second metatarsal212.

To help avoid a base shift, a clinician can insert a fulcrum in thenotch between first metatarsal 210 and second metatarsal 212 at the baseof the metatarsals (e.g., adjacent respective cuneiform) beforeactuating bone positioning guide 10 or otherwise moving the firstmetatarsal relative to the medial cuneiform. The fulcrum can provide apoint about which first metatarsal 210 can rotate and/or pivot whilehelping minimize or avoid base compression between the first metatarsaland the second metatarsal. Instrument 300 can be used as the fulcrum oranother instrument providing fulcrum functionality can be used.

In applications utilizing bone positioning guide 10, the actuator on thebone positioning guide can be actuated to reduce the angle (transverseplane angle between the first metatarsal and the second metatarsal) androtate the first metatarsal about its axis (frontal plane axialrotation). The first metatarsal 210 can be properly positioned withrespect to the medial cuneiform 222 by moving the bone engagement member40 bone positioning guide with respect to the tip 50 of the bonepositioning guide. In some embodiments, such movement simultaneouslypivots the first metatarsal with respect to the cuneiform and rotatesthe first metatarsal about its longitudinal axis into an anatomicallycorrect position to correct a transverse plane deformity and a frontalplane deformity. Other instrumented and/or non-instrumented approachescan be used to adjustment position of first metatarsal 210 relative tomedial cuneiform 222. Thus, other applications utilizingcompressor-distractor 100 and instrument 300 may be performed withoututilizing bone positioning guide 10.

Independent of whether bone positioning guide 10 is used, an exampletechnique may include positioning joint spacer 188 within the jointbetween first metatarsal 210 and medial cuneiform 222, as illustrated inFIG. 18 . Bone preparation guide 150 can be placed over the joint spacer188 as shown in FIG. 19 and engaged with the joint spacer to set aposition and orientation of the bone preparation guide relative to thejoint. In other embodiments, bone preparation guide 150 is placed on thebones without using joint spacer 188 to aid with positioning.

As depicted in FIG. 20 , one or more fixation pins can be inserted intoapertures of the bone preparation guide 150 to secure the guide to thefirst metatarsal 210 and the medial cuneiform 222. The fixation pinsinserted into the apertures of bone preparation guide 150 includes afirst fixation pin 112 and second fixation pin 114. The first and secondfixation pins 112, 114 may be inserted in substantially parallelalignment. The first and second fixation pins 112, 114 may project atleast 25 mm above the surface of the bones into which the pins areinserted, such as at least 50 mm, or at least 75 mm. One or moreadditional pins can be inserted at an angle or in a convergingorientation to help prevent movement of the bone preparation guide 150during a tissue removing step. After insertion of the pins, the spacer188 (if used) can optionally be removed in embodiments having aselectively engageable spacer.

In some applications, the end of the first metatarsal 210 facing themedial cuneiform 222 can be prepared with a tissue removing instrument296 guided by a guide surface of bone preparation guide 150 (e.g.,inserted through a slot defined by a first guide surface and a firstfacing surface). In some embodiments, the first metatarsal 210 endpreparation is done after at least partially aligning the bones, e.g.,by actuating bone positioning guide 10 or otherwise moving the firstmetatarsal but after preparing the end of first metatarsal 210. In otherembodiments, the first metatarsal 210 end preparation is done before thealignment of the bones, e.g., by preparing the end of the firstmetatarsal 210 before installing compressor-distractor 100 andinstrument 300.

In addition to preparing the end of first metatarsal 210, the end of themedial cuneiform 222 facing the first metatarsal 210 can be preparedwith the tissue removing instrument 296 guided by a guide surface ofbone preparation guide 150 (e.g., inserted through a slot defined by asecond guide surface and a second facing surface). In some embodiments,the medial cuneiform 222 end preparation is done after the alignment ofthe bones. In yet other embodiments, the medial cuneiform 222 endpreparation is done before the alignment of the bones. In embodimentsthat include cutting bone or cartilage, the cuneiform cut and themetatarsal cut can be parallel, conforming cuts. In some examples, a sawblade can be inserted through a first slot to cut a portion of themedial cuneiform and the saw blade can be inserted through a second slotto cut a portion of the first metatarsal.

Any angled/converging pins can be removed and the bone preparation guide150 can be lifted off the substantially parallel first and second pins112, 114, as shown in FIG. 21 . These substantially parallel pins canreceive compressor-distractor 100. For example, the clinician canposition compressor-distractor 100 so the bottom side of firstpin-receiving hole 108 is positioned over first pin 112 and the bottomside of second pin-receiving hole 110 is positioned over second pin 114.The clinician can then slide compressor-distractor 100 down over thepins toward the underlying bones, e.g., until the bottom side of thecompressor-distractor is adjacent to or in contact with the underlyingbones. The clinician may adjust the spacing between first engagement arm102 and second engagement arm 104 by actuating actuator 106 until theseparation distance corresponds to the spacing between first and secondpins 112, 114, before installing the compressor-distractor down over thepins. If first pin-receiving hole 108 is angled relative to secondpin-receiving hole 110, the process of inserting compressor-distractor100 on the pins can cause first and second pins 112, 114 to shift fromtheir substantially parallel alignment to a nonparallel alignmentcorresponding to the angular position of the pin-receiving holes. Bycontrast, when first pin-receiving hole 108 is parallel to secondpin-receiving hole 110, the process of inserting compressor-distractor100 on the pins may not cause first and second pins 112, 114 to shiftsubstantially from their parallel alignment.

In applications where bone positioning guide 10 is utilized, the bonepositioning guide may be removed before or after bone preparation guide150 is removed and compressor-distractor 100 is installed. In eithercase, in some examples, a temporary fixation device such as an olivepin, k-wire, or other fixation structure may be used to maintain theposition of the underlying bones (e.g., first metatarsal 210 relative tomedial cuneiform 222) while bone preparation guide 150 is removed andcompressor-distractor 100 is installed.

With compressor-distractor 100 pinned to underlying bones (e.g., firstmetatarsal 210 and medial cuneiform 222), actuator 106 may be actuatedto distract the underlying bones. For example, the clinician may turnknob 126 to cause second engagement arm 104 to move away from firstengagement arm 102, opening or enlarging a gap between the underlyingbones. When pin to first metatarsal 210 and medial cuneiform 222, theclinician can actuate actuator 106 to open the TMT joint. While in thisexample application compressor-distractor 100 is described as beingattached to first metatarsal 210 and medial cuneiform 222 to distractthe two bones (e.g., followed by subsequent compression), alternativeimplementations may involve manual distraction of the bones. In thesealternatives, the clinician may attach compressor-distractor 100 tofirst metatarsal 210 and medial cuneiform 222 after distracting the twobone portions, e.g., and only utilize the compression feature ofcompressor-distractor 100 without utilizing the distraction feature.

In either case, with the underlying bones distracted, the clinician mayclean or otherwise prepare the space between the bones and/or the endface of one or both bones. The clinician may clean the space by removingexcess cartilage, bone, and/or other cellular debris that may nativelyexist or may have been created during the bone preparation step that mayinhibit infusion. FIG. 22 is a perspective view of a foot showing anexample distracted position of compressor-distractor 100 in which firstmetatarsal 210 is spaced from medial cuneiform 222. In this example,bone debris from the prepared end of first metatarsal 210 and theprepared end of medial cuneiform 222 is illustrated as being positionedin the tarsal-metatarsal space. The clinician can remove this debris orperform other desired clean-up with the two bones distracted from eachother.

Independent of whether the clinician utilizes compressor-distractor 100to distract the underlying bones for cleaning, the clinician can insertinstrument 300 defining a sliding surface between first metatarsal 210and second metatarsal 294. FIG. 23 is a perspective view of a footshowing an example positioning of instrument 300 relative to firstmetatarsal 210. In this example, instrument 300 defines a slidingsurface 412, which is positioned between first metatarsal 210 and secondmetatarsal 212. Sliding surface 412 can be positioned at any desiredlocation (e.g., in the distal to proximal direction) along the lengthsof the first and second metatarsals.

In some implementations, such as that illustrated in FIG. 23 ,instrument 300 is positioned between the prepared end or base of firstmetatarsal 210 and second metatarsal 212. For example, instrument 300may be positioned between a lateral side of the prepared end of firstmetatarsal 210 and a medial side of second metatarsal 212. The edge ofthe prepared end of first metatarsal 210 may be positioned in the planeof sliding surface 412 or, in other applications, may be positionedproximally or distally of sliding surface 412. Instrument 300 may or maynot contact the medial side of second metatarsal 212 in addition tocontacting the lateral side of first metatarsal 210.

In any application, instrument 300 and sliding surface 412 may helpmedialize first metatarsal 210 as compressor-distractor 100 is actuatedto compress first metatarsal 210 toward medial cuneiform 222. Ascompressor-distractor 100 is actuated to move first metatarsal 210generally axially (e.g., in the proximal direction) toward medialcuneiform 222, the prepared end of the metatarsal and/or a lateralportion of the first metatarsal may translate in contact with and/oracross sliding surface 412. The presence of sliding surface 412 betweenfirst metatarsal 210 and second metatarsal 212 can help prevent or limitthe extent to which the first metatarsal (e.g. prepared end of themetatarsal) catches on tissue, boney substrate (e.g., the surface ofsecond metatarsal 212), or other obstructing matter.

In some examples, instrument 300 defining sliding surface 412 may bepositioned substantially stationary (non-moving) between firstmetatarsal 210 and second metatarsal 212 as first metatarsal 210 ismoved generally axially toward medial cuneiform 222. In otherimplementations, instrument 300 defining sliding surface 412 may bemoved as first metatarsal 210 is moved toward medial cuneiform 22. Forexample, the clinician may grasp or otherwise hold instrument 300 andmove the position of the instrument as first metatarsal 210 iscompressed toward and/or against the medial cuneiform 222.

Instrument 300 defining sliding surface 412 can be inserted betweenfirst metatarsal 210 and second metatarsal 212 as any desired timeduring the surgical procedure. In the illustrated arrangement,instrument 300 is depicted as being inserted between the two boneportions after removal of bone preparation guide 150 and distraction offirst metatarsal 210 from medial cuneiform 222 but prior to compressionof the first metatarsal to the medial cuneiform. As another example, theclinician may distract the first metatarsal 210 from medial cuneiform222, preform any desired clean-up, and begin compressing the firstmetatarsal toward the medial cuneiform. The clinician may observe wherefirst metatarsal 210 is frictionally interfering with obstructing matter(e.g., second metatarsal 212) during the initial compression and insertinstrument 300 to inhibit further interference. As yet a furtherexample, the clinician may utilize instrument 300 as both a fulcrum andan instrument defining a sliding surface, as discussed above. In theseapplications, the clinician may insert instrument 300 to function as afulcrum during earlier bone realignment and leave the instrument in theintermetatarsal space, e.g., for the duration of the surgical procedure.Thus, instrument 300 may be present in the intermetatarsal space duringdistraction and compression, although the clinician may realign theinstrument within the intermetatarsal, e.g., immediately prior to orduring the compression phase.

Independent of when the clinician inserts instrument 300, the clinicianmay actuate actuator 106 to compress the bones together for permanentfixation infusion. The clinician may turn knob 126 to cause secondengagement arm 104 to move toward first engagement arm 102, for exampleuntil the end faces of the underlying bones contact each other and/or acompressive force is applied through pins 112, 114 to the end faces, asillustrated in FIG. 24 . While in this example applicationcompressor-distractor 100 is described as being used to compress the twobones, alternative implementations may involve manual compression of thebones or compression using a different instrument. In thesealternatives, the clinician may attach compressor-distractor 100 tofirst metatarsal 210 and medial cuneiform 222 to distract the two boneportions, e.g., and only utilize the distraction feature ofcompressor-distractor 100 without utilizing the compression feature.

With the end faces pressed together via compressor-distractor 100, theclinician may provisionally or permanently fixate the bones or bonesportions together. For example, one or more bone fixation devices can beapplied across the joint and to the two bones to stabilize the joint forfusion, such as two bone plates positioned in different planes. FIG. 25illustrates an example fixation device arrangement that includes a firstbone plate 310 positioned on a dorsal-medial side of the firstmetatarsal and medial cuneiform and a second bone plate 320 positionedon a medial-plantar side of the first metatarsal and the medialcuneiform. In other embodiments, second bone plate 320 can be a helicalbone plate positioned from a medial side of the cuneiform to a plantarside of the first metatarsal across the joint space. The plates can beapplied with the insertion of bone screws. Example bone plates that canbe used as first bone plate 310 and/or second bone plate 320 aredescribed in US Patent Publication No. US2016/0192970, titled “BonePlating System and Method” and filed Jan. 7, 2016, which is incorporatedherein by reference. Other types in configurations of bone fixationdevices can be used, and the disclosure is not limited in this respect.

Compressor-distractor devices and instruments providing slidingsurfaces, along with associated techniques and systems, have beendescribed. In some examples, a compressor-distractor and instrumentdefining a sliding surface according to the disclosure is included in adisposable, sterile kit that includes associated surgicalinstrumentation, such as bone positioning guide and/or a preparationguide described herein. Other components that may be included within thesterile kit include bone fixation devices, bone fixation screws, pinsfor insertion into pin-receiving holes, and the like.

Various examples have been described. These and other examples arewithin the scope of the following claims.

The invention claimed is:
 1. A method comprising: attaching a compressor-distractor to a first metatarsal; attaching the compressor-distractor to a medial cuneiform; inserting an instrument defining a sliding surface between the first metatarsal and a second metatarsal; and actuating the compressor-distractor to move the first metatarsal toward the medial cuneiform, thereby causing the first metatarsal to slide across the sliding surface of the instrument as the first metatarsal is moved toward the medial cuneiform.
 2. The method of claim 1, wherein the instrument has a length extending from a leading end to a trailing end and tapers in thickness along at least a portion of the length from the trailing end to the leading end.
 3. The method of claim 1, wherein the instrument has a generally rectangular cross-sectional shape or a generally circular cross-sectional shape.
 4. The method of claim 1, wherein the instrument has a body and a handle operatively connected to the body, and the handle projects at a non-zero degree angle from the body to define a tissue retraction space between the handle and the body.
 5. The method of claim 1, further comprising actuating the compressor-distractor to move the first metatarsal away from the medial cuneiform.
 6. The method of claim 5, wherein inserting the instrument between the first metatarsal and a second metatarsal comprises inserting the instrument after actuating the compressor-distractor to move the first metatarsal away from the medial cuneiform but prior to actuating the compressor-distractor to move the first metatarsal toward the medial cuneiform.
 7. The method of claim 5, wherein actuating the compressor-distractor to move the first metatarsal toward the medial cuneiform comprises moving an end of the first metatarsal generally axially toward an opposed end of the medial cuneiform, causing at least one of the end of the first metatarsal and a lateral side of the first metatarsal to slide across the sliding surface of the instrument as the first metatarsal is moved toward the medial cuneiform.
 8. The method of claim 5, further comprising, while the compressor-distractor is actuated to move the first metatarsal away from the medial cuneiform, cleaning a space between the first metatarsal and the medial cuneiform, and wherein actuating the compressor-distractor to move the first metatarsal toward the medial cuneiform comprises moving the first metatarsal toward the medial cuneiform until the first metatarsal is compressing against the medial cuneiform.
 9. The method of claim 5, where actuating the compressor-distractor to move the first metatarsal away from the medial cuneiform comprises moving the first metatarsal away from the medial cuneiform a distance ranging from 1 millimeter to 2.5 millimeters.
 10. The method of claim 1, wherein inserting the instrument between the first metatarsal and a second metatarsal comprises positioning the instrument between a lateral portion of the first metatarsal and a medial portion of the second metatarsal.
 11. The method of claim 1, wherein the instrument further functions as a fulcrum, and further comprising, prior to attaching the compressor-distractor to the first metatarsal and the medial cuneiform, moving a distal portion of first metatarsal toward the second metatarsal in a transverse plane, thereby pivoting a proximal portion of the first metatarsal about the instrument and reducing an intermetatarsal angle between the first metatarsal and the second metatarsal.
 12. The method of claim 1, wherein: the compressor-distractor comprises a first engagement arm, a second engagement arm, and an actuator operatively coupled to the first engagement arm and the second engagement arm, attaching the compressor-distractor to the first metatarsal comprises attaching the first engagement arm to the first metatarsal; attaching the compressor-distractor to the medial cuneiform comprises attaching the second engagement arm to the medial cuneiform; and actuating the compressor-distractor to move the first metatarsal toward the medial cuneiform comprises engaging the actuator operatively coupled to the first engagement arm and the second engagement arm to move the first engagement arm toward the second engagement arm.
 13. The method of claim 12, wherein the actuator comprises a shaft connected to the first engagement arm and the second engagement arm.
 14. The method of claim 1, wherein attaching the compressor-distractor to the first metatarsal and attaching the compressor-distractor to the medial cuneiform comprises: inserting a first pin into the first metatarsal; inserting a second pin into the medial cuneiform; positioning the first pin through a first pin-receiving hole of a first engagement arm of the compressor-distractor; and positioning the second pin through a second pin-receiving hole of a second engagement arm of the compressor-distractor.
 15. The method of claim 14, further comprising prior to inserting the first pin and the second pin, positioning a first fixation aperture of a bone preparation guide over the first metatarsal and a second fixation aperture of the bone preparation guide over the medial cuneiform, the first and second fixation apertures being parallel to each other, wherein inserting the first pin and the second pin comprises inserting the first pin through the first fixation aperture of the bone preparation guide into the first metatarsal and the second pin through the second fixation aperture of the bone preparation guide into the medial cuneiform.
 16. The method of claim 1, further comprising moving the first metatarsal from a first position with respect to the second metatarsal to a second position with respect to the second metatarsal by applying a force to the first metatarsal, the force moving the first metatarsal in at least one plane.
 17. The method of claim 16, wherein moving the first metatarsal from the first position to the second position comprises moving the first metatarsal prior to attaching the compressor-distractor to the first metatarsal and to the medial cuneiform.
 18. The method of claim 1, further comprising: moving the instrument defining the sliding surface with the first metatarsal as the first metatarsal is moved toward the medial cuneiform via actuation of the compressor-distractor.
 19. A method comprising: attaching a compressor-distractor to a first metatarsal; attaching the compressor-distractor to a medial cuneiform; actuating the compressor-distractor to move the first metatarsal away from the medial cuneiform; and inserting an instrument defining a sliding surface between the first metatarsal and a second metatarsal.
 20. The method of claim 19, wherein the instrument has a length extending from a leading end to a trailing end and tapers in thickness along at least a portion of the length from the trailing end to the leading end.
 21. The method of claim 19, wherein the instrument has a generally rectangular cross-sectional shape or a generally circular cross-sectional shape.
 22. The method of claim 19, wherein inserting the instrument between the first metatarsal and a second metatarsal comprises inserting the instrument after actuating the compressor-distractor to move the first metatarsal away from the medial cuneiform.
 23. The method of claim 19, further comprising, while the compressor-distractor is actuated to move the first metatarsal away from the medial cuneiform, cleaning a space between the first metatarsal and the medial cuneiform.
 24. The method of claim 19, where actuating the compressor-distractor to move the first metatarsal away from the medial cuneiform comprises moving the first metatarsal away from the medial cuneiform a distance ranging from 1 millimeter to 2.5 millimeters.
 25. The method of claim 19, wherein inserting the instrument between the first metatarsal and a second metatarsal comprises positioning the instrument between a lateral portion of the first metatarsal and a medial portion of the second metatarsal. 